The overall conclusion from the research conducted for this report is the following:

Transcription

1 REGULATORY AND FUNDING PARAMETERS FOR PEER SPECIALISTS IN SUPPORTING EMPLOYMENT Prepared by Carol Ward-Colasante, Consultant, Temple University Collaborative on Community Inclusion of Individuals with Psychiatric Disabilities, under contract with the Pennsylvania Office of Mental Health and Substance Abuse Services, August, 2012 Executive Summary The purpose of this paper is to encourage and strengthen the role that peer specialists in Pennsylvania can play in supporting the competitive employment goals of individuals who have a serious mental illness, while at the same time ensuring that employment supports are provided in a manner consistent with regulatory and funding guidelines. Since the majority of peer specialists in Pennsylvania are funded through Pennsylvania s approved Medicaid rehabilitation option and provided through HealthChoices, Pennsylvania s Medicaid funded managed care program, it is critical that employment related services are provided and documented within Medicaid funding and regulatory guidelines. Federal Medicaid experts and state mental health policy leaders were interviewed for the development of this paper and confirmed that there are few federal policies that clarify the provision of employment related services through Medicaid. This paper, nonetheless, attempts to summarize the intent of federal policies, as well as policies specific to Pennsylvania that guide what employment related supports can be provided by peer specialists within Pennsylvania s Medicaid plan. The overall conclusion from the research conducted for this report is the following: There is opportunity within Pennsylvania s Medicaid state plan for peer specialists to encourage and support consumers vocational goals, if done so in a way that addresses functional impairments due to a mental illness and is properly documented within the record. Other key conclusions include: T T In Pennsylvania, peer services are funded through a Medicaid rehabilitation option and therefore, federal Medicaid policies pertaining to the rehabilitation option is what 1

2 guides the type of employment services peers specialists can provide within the state under Medicaid. Services traditionally provided by the Office of Vocational Rehabilitation and vocational provider agencies such as job training, employment assessments, and job coaching are not covered by Medicaid under the rehabilitation option. Other Medicaid options, such as 1915(i) and 1915(c), allow for Medicaid reimbursement of employment services; however, these Medicaid options do not exist in Pennsylvania for persons with a mental illness. Pennsylvania Bulletin issued January 1, 2010, guides the licensing and approval of peer support services in Pennsylvania and peer support services can include goals related to employment. Peer specialists may be able to provide a much broader array of employment services if funded by sources other than Medicaid. Peer specialists are encouraged to receive training on employment services to increase their general knowledge about employment and the evidence-based practice of supported employment for persons with a mental illness. Clear and comprehensive documentation of employment supports, as they relate to a person s functional impairment due to a mental illness, must be included in the individual s record. Introduction Peer support services are widely available across Pennsylvania due in large part to Medicaid financing of the service. Medicaid funded peer services can be provided within an approved range of service settings in the state, including: psychiatric rehabilitation programs, psychiatric outpatient clinics, partial hospitalization programs, crisis intervention providers, free-standing peer specialist programs, resource coordination and intensive case management services. Peer specialists may also be employed in non-medicaid funded peer support service providers in PA such as drop-in centers, vocational programs, assertive community treatment, state mental hospitals, county offices, or other service settings as designated by various funding sources. While this paper will focus primarily on the guidelines, regulations and documentation requirements for Pennsylvania s Medicaid funded peer specialist program, it encourages the expanded role of peer specialists in supporting competitive employment goals throughout the service system. Peer Specialists as a Support to Employment Goals In 2006, The Pennsylvania Office of Mental Health and Substance Abuse Services received approval from the Centers for Medicare and Medicaid services (CMS) for Peer Support Services 2

3 through an approved rehabilitation option plan. Peer support services are defined in Pennsylvania as specialized therapeutic interactions conducted by self-identified current or former consumers of behavioral health services who are trained and certified to offer support and assistance in helping others in their recovery and community integration process. 1 Pennsylvania has also promoted increased attention to the competitive employment goals of people with mental illnesses, and in particular the development of the evidence-based practice of supported employment for persons with psychiatric disabilities. This commitment is reflected in the state employment plan: Employment : a Key to recovery. 2 The principles of the evidence-based practice of supported employment as outlined by the Substance Abuse and Mental Health Services Administration 3 include: 1) Eligibility is based on consumer choice; 2) Supported employment is integrated with treatment; 3) Competitive employment is the goal; 4) Job search starts soon after a consumer expresses interest in working; 5) Follow-along supports are continuous; 6) Consumer preferences are important; and 7) SE provides benefit counseling. Peer specialists are encouraged to receive training on the evidence-based practice of supported employment for persons with psychiatric disabilities so that these principles guide the support that they provide to the persons they work with; however, it is recognized that many peer specialists will not be working in or directly as a part of a supported employment program. All peer specialists are encouraged to address employment issues with those they serve keeping in mind two important principles: first, each peer specialist should stay true to their role as a peer and utilize their lived experiences to support others in their employment journey; and second, rather than becoming vocational specialists (unless that is a career goal that peers want to consider), peers should become sufficiently familiar with available vocational resources in order to broker, rather than duplicate, specialized employment services from which persons can benefit. There is sufficient research to indicate that competitive employment goals are a significant part of the hopes and desires of many peers, and peer specialists can and should play a central role in supporting these aspirations. More information about the defined role of peer specialists within Pennsylvania standards are outlined under Peer Roles In and Outside of Medicaid listed below. Training opportunities are outlined in the below section entitled Training for Peer Specialists on Employment. Peer Roles In and Outside of Medicaid Peer support services were added to the Pennsylvania Medicaid plan under an approved rehabilitation option in With the approval of peer support services as a Medicaid service, Pennsylvania decided to add this service to the list of required services offered under the HealthChoices Behavioral Health program. With the addition of certified peer support services 3

4 to Pennsylvania s managed care program, each contractor must offer a choice of two peer support providers that either provide mobile services or are within a reasonable commuting distance. Approved providers of Medicaid funded peer specialist services must be licensed to provide the service. The receipt of Medicaid funding for the service carries with it requirements for compliance with federal and state regulations, policies and documentation requirements. What guides the type of employment supports that peer specialists can provide under Medicaid funding? Historically, employment services including supported employment, have been funded through a blending or braiding of funding streams including mental health, vocational rehabilitation, social security, education and Medicaid, since no one source of funding can fully support all employment activities due to differences in eligibility and policy across funding streams. The lack of a consistent and primary funding source for employment services has created barriers to the development and sustainability of these services. Within Medicaid, few official documents are available that clearly describe what employment related services are allowed or prohibited, which creates a barrier to states in using this funding stream to promote employment. In October of 2009, a group of state policy makers came together to discuss the challenges specifically related to providing supported employment to persons with mental illness within state Medicaid programs. Participants were in agreement that additional guidance from CMS on how states can effectively and confidently use Medicaid funding to reimburse for supported employment services is critical. 4 Recent federal audits (see section on Documentation ) created further questions regarding services that are specifically permitted under the rehabilitation option. It should be noted that there are a variety of Medicaid options and the kind of option and content of that option within each state s Medicaid plan drives what is allowed and prohibited within that state. Elements of employment can be provided through a Medicaid rehabilitation option, a 1915 (i) state plan amendment, and 1915 (c) or (b) waivers. This document will focus on what is currently permitted within Pennsylvania s Medicaid plan and will briefly address what other Medicaid options allow. See Attachment A for a chart that outlines the Medicaid options, what employment services they permit, and which are available within Pennsylvania. In Pennsylvania, the Medicaid funding source that allows peer specialists to assist people with their employment goals is the Rehabilitation State Plan for Certified Peer Support Services. Through this state Medicaid plan, Certified Peer Support Services were added as a mandatory service to Pennsylvania s 1915(b)-managed care waiver, HealthChoices, thereby requiring statewide availability of the service, as noted above. The federal and state documents that 4

5 guide how peer support services can assist with employment goals in Pennsylvania are outlined below: Federal Guidance: Letter from Medicaid Director, Christine Nye, 1992 on the Rehabilitation option 5 This letter issued from the Center for Medicaid and Medicare services (CMS) in 1992 is the primary guidance regarding what is allowable under the optional rehabilitation benefit (which is how Peer Support Services were approved in Pennsylvania). The letter states while it is not always possible to determine whether a specific service is rehabilitative by scrutinizing the service itself, it is more meaningful to consider the goal of the treatment. Services necessary for the treatment of mental illness may be coverable as rehabilitative services. The letter goes on to describe two major services which are allowed under the rehabilitation option: 1) basic living skills (which means helping a person to restore skills such as food planning, maintaining a living environment, etc.) and 2) counseling and therapy. The letter also outlines what does not fall under the rehabilitation option: 1) vocational training (which includes job training, vocational and educational services), 2) personal care services (performed for the recipient as opposed to teaching the recipient are not allowed) and 3) case management (directed to managing non-medicaid services are not covered). It should be noted that personal care and case management, while not permitted here, are covered as separate services under Medicaid. No further definitions are provided regarding the vocational terms above, but one can assume that this is referring to the types of services funded through the Department of Labor and Industry s Office of Vocational Rehabilitation and similar services offered by vocational providers. It is also important to rely upon the overall definition of rehabilitation services within federal regulation to help clarify what is allowed. Thus, under the rehabilitation option, states can cover medical or remedial services for the maximum reduction of physical or mental disability and restoration of a recipient to the best possible functional level. From this document, one can conclude that the type of services that can be provided by peer specialists that are assisting with employment goals and the way in which they must be documented under the rehabilitation option, are as rehabilitative services that assist in restoring a person s functioning. Medicaid Support of Evidence-Based Practices In Mental Health Programs 6 This document, prepared by CMS in 2005, describes how six evidence-based practices, including supported employment, can be funded through Medicaid services. On the one hand, the document indicates that supported employment and pre-vocational 5

6 training cannot be covered through the state Medicaid plan, and further states that vocational training is among the few services statutorily excluded from Medicaid reimbursement and similarly, payment may not be made for employment assessments, or ongoing support to maintain employment (except under an HCBS waiver, which we do not have in Pennsylvania for persons with a mental illness). On the other hand, the document further states, that Medicaid can pay for medical services that enable an individual to function in the workplace, including a psychiatrist s or psychologist s treatment, rehabilitation planning, therapy and counseling (please note that the CMS letter SMDL # below uses the term counseling to describe peer services). As concluded in the above document, Medicaid-funded peer support services related to an individual s employment goals should be provided and documented in relation to the functional impairment as a result of the mental illness to allow an individual to function in the workplace. Peer specialists should not, however, be providing or documenting their services as vocational which include employment assessments, pre-vocational training, job development, job coaching, etc. Individuals in need of those services should be referred to the Office of Vocational Rehabilitation or a vocational provider agency. CMS letter SMDL # August 15, 2007 regarding peer services 7 This letter issued by CMS recognizes the shift in the mental health field to recovery and Medicaid support for peer services. The SMDL # letter describes peer support providers as a distinct provider type for the delivery of counseling and other support services to Medicaid eligible adults with mental illnesses and/or substance use disorders. It is interesting to note that CMS uses the term counseling as well as support services to describe peer support services. While it is unlikely that people in the field would describe peer services as counseling (and the OMHSAS Peer Support Services bulletin does not include counseling as a peer support service), it may be a way for CMS to encompass this service within their current medical/clinical lingo (Note the use of the term counseling in the both the 1992 Medicaid letter and the 2005 CMS evidence-based practice documents above). This policy sets requirements for states to have peers supervised by a mental health professional, a person-centered planning process and training for peers. Pennsylvania has all of these requirements in place. State Guidance: 6

7 OMHSAS Peer Support Services Bulletin-09-07, and provider handbook, January 1, This Pennsylvania bulletin and provider handbook guides the licensing and approval of peer support services within the Commonwealth. Eligibility for peer services includes a moderate to severe functional impairment that limits performance in at least one domain including the vocational domain. Goals for the services may be in the areas of wellness and recovery, employment, crisis support, housing, social networking, selfdetermination and individual advocacy. Therefore, it is clear that peer services can include assisting an individual with functional impairments due to a mental illness that interferes with employment. Peer support services include: crisis support, development of community roles and natural supports, individual advocacy, self-help, self-improvement, and assistance with social networks. Employment supports related to employment should be provided to an individual consistent with the services outlined in this bulletin. Why do some states provide a broader array of employment services under Medicaid? Frequently, people ask why other states offer a broader array of employment services under Medicaid than are permitted in Pennsylvania. The answer is that there are additional Medicaid options that some states have utilized to expand the range of services, including employment supports. It is worth reviewing these Medicaid options, since Pennsylvania may want to consider these options in the future. Attachment A provides an overview of federal Medicaid options that are available to states and what each option permits related to employment services. Pennsylvania currently operates its peer specialist program under a Medicaidapproved 1905(a) 13 rehabilitation option. The peer specialist program operates within Pennsylvania s 1915(b) HealthChoices managed care program as a required in-plan service. Neither the 1915(i) or 1915(c) Home and Community Based Services waiver programs exist within Pennsylvania for persons with mental illness. The 1915(c) program does exist in Pennsylvania for persons with other disabilities such as those with intellectual disabilities. Under the Home and Community Based (HCBS) waiver, work specific assessments and training are permitted. Home and Community Based waivers have been used by states for persons with mental illness on a very limited basis due to the federal eligibility requirements to document cost effectiveness of community services as an alternative to institutional services. Some states are beginning to apply for 1915(i) services which do permit a full range of services, including employment services. If at some point Pennsylvania considers changing or adding a new Medicaid option to the state Medicaid plan, it would be advisable to include employment services for persons with mental illness within the service array. 7

8 What employment services are permitted outside of peer specialist Medicaid funding? Peer specialists are working throughout Pennsylvania in a variety of non-medicaid approved and licensed peer specialist programs. This would include service settings such as drop-in centers, vocational programs, assertive community treatment, state mental hospitals, county offices, etc. These services are typically funded through state, county, local or other funding. Peer specialists that work within these settings are subject to licensing, funding and policy standards that are set forth by the provider type in which they work and the funding source. As a result, there may be considerably more flexibility regarding the range of employment services a peer specialist might be able to provide in these settings. For example, a peer specialist may be working within a county-funded vocational program, psychiatric rehabilitation program, or drop-in center. In all of these cases, peers are not subject to the federal regulations/policies listed above and may or may not be subject to the state standards and should check with their funding entities for clarification on applicable policies. In summary, peer specialists may be a valuable resource in assisting individuals with their employment goals and may have considerable flexibility to provide a broad range of employment supports outside of the Medicaid funded and licensed peer support program in Pennsylvania. However, these services are subject to policies/regulations as mandated by the funding source. Training for Peer Specialists on Employment Under a grant from the Center for Mental Health Services within the Substance Abuse and Mental Health Services Administration, Pennsylvania will be developing training for peer specialists on employment supports. Pennsylvania s two peer training institutes will each develop a training program; The Institute for Recovery and Community Inclusion within the Mental Health Association of Southeast Pennsylvania will design and implement a 2 day classroom curriculum, and Recovery Opportunity Center of Arizona will design and implement a 7-9 hour e-learning curriculum. Both options will be available in the fall of 2012 for peer specialists who have completed the two week peer specialist orientation. These courses will be uniquely designed for peer specialists. Boston University is also in the process of testing a 6 day employment curriculum for peer specialists that will be made available more widely in the future. Peer specialists that wish to increase their general knowledge about employment and the particular evidence-based intervention of supported employment for persons with psychiatric disabilities can also find trainings available through Virginia Commonwealth University and George Washington University. Trainees should be aware that some of these courses address supported employment from a cross-disability perspective and may not capture the unique practices of supported employment for persons with mental illness. 8

9 Training and further education for peer specialists in the area of employment may serve as a career ladder for peers that want to move into this specialized field of service. Documentation All Medicaid funded services, including Medicaid funded and licensed peer support services, must be documented according to Medicaid requirements. Documentation must include all of the elements listed below (see figure 1). This includes: who the services are being provided to, what the particular service is that is being provided, when the service is provided, how long the service is provided, where it is provided, the purpose of the service (as it relates to the individual service plan), and the status (again as it relates to the person s individual service plan). If any of this information is missing, the service can be determined as not having met the requirements for Medicaid payment and therefore not eligible for reimbursement. While these documentation elements are standard for many services both in and outside of Medicaid funding, documentation for some peer support services provided outside of Medicaid funding may not be as rigorous. For example, consumer run drop-in centers may not collect such detailed information due to the peer nature of the service and lack of requirement to bill for individual units of service. If a provider/peer specialist is in doubt regarding the required documentation requirements within their program, they should consult their supervisor. Beyond the basic Medicaid documentation requirements described here and listed in figure 1, it is extremely important that employment-related peer supports are provided and documented according to Medicaid standards. In the section above on Peer Roles In and Outside of Medicaid, it was noted that certain employment services are prohibited under Pennsylvania s rehabilitation option which funds licensed peer support services. These prohibited services include such things as: employment assessments, vocational training, and job development. However, other types of services can be provided to help a person address their functional impairments due to their mental illness that interfere with seeking, obtaining and maintaining a job. (See figure2) In order for peer support services with a goal of employment to be Medicaid reimbursable, the service must focus on helping a person overcome or address psychiatric symptoms that interfere with seeking, obtaining and maintaining a job. Positive psychiatric symptoms include auditory or visual hallucinations, incoherence or marked loosening of associations, delusions, etc. Negative symptoms include apathy, lethargy, and ambivalence, flattening of emotions, isolation and withdrawal. 8 Examples of peer support employment services are provided in Attachment B. Medicaid audits and documentation issues: A small number of states have had their rehabilitation programs audited by the Office of Inspector General. The audits show that large numbers of reviewed claims were disallowed. 9

10 The major reasons for these disallowances were: inadequate documentation and billing errors and services that were found to not be rehabilitative in nature. 9 Peer specialists and peer specialist supervisors should work with their program administrator and behavioral health managed care organization and county for guidance on defining the roles of peer specialists locally and in developing documentation protocols that will be needed to pass managed care and Medicaid audits. 10

11 What Status When Who Purpose Where How long FIGURE 1: DOCUMENTATION REQUIREMENTS 11

13 ATTACHMENT A MEDICAID PLAN OPTIONS AND COVERED EMPLOYMENT SERVICES* Employment related services covered Medical or remedial services related to a medical condition that enables an individual to function in the workplace Work specific assessment and training 1905 (a)13 Rehab option Yes (Under Peer support services plan in PA) No 1915(i) Yes (Waiver does not exist in PA) Yes (If no other payer) 1915(c) Home and community based services Yes (Waiver does not exist in PA for persons with mental illness) Yes (if no other payer) 1915(b) Managed care waiver Yes, If service is in the state Medicaid plan. (Is available through Peer support services) No (unless included in a (b) (c) combination waiver or a 1915(i) program implemented in managed care) *Adapted from Making MH Evidence-based practices work for Medicaid Beneficiaries: Supported Employment Oct 7, 2009, Ron Hendler, CMS. 10 Shaded columns indicate under which authority peer support services are made available in Pennsylvania and the employment related service covered under that authority. 13

14 Attachment B Certified Peer Support Services: Examples that Support Employment Explore: Do I want to work at this time? Services provided by peer specialists Purpose: Help person to assess potential effects of working on his/her life Inspire and create excitement about work and how to use and enhance a person s strengths through employment Examples: Discuss strengths and what gets in the way of working/returning to school in light of person s current mental health recovery CPS uses their own personal employment journey to discuss person s feelings about going to work/receiving further education Shares the benefits of working (financial, social connections, get off SSI, making a contribution, doing something the world values-the normal thing people do) and how it s a life enhancement Helps person explore education/training needed to pursue career goals such as GED, community college, technical schools and how the person s illness may have interfered with these goals Peer specialist shares how he/she overcame their ambivalence and used determination to return to work Peer specialist shares information on the effects that working can have on benefits (SSI, SSD, MA) and that working part time is okay until a person is ready to move up Services provided by vocational providers (NOTE! These services cannot be provided by peer specialists under Medicaid!) Not applicable until person has made a decision to return to work 14

15 Provides brochure on Ticket to Work and current SSA Red Book on work incentives Assists person in navigating work incentives/benefits area of SSA.gov website Discusses possible linkage to benefits counselor Helps individual find a person who can assist with the Medical Assistance for Workers with Disabilities (MAWD) program and how it can provide possible coverage for medical costs while working Facilitates/mediates conversation between the person and relevant others who may not support their goal of working-treatment team, family, significant others- and shares how to believe in yourself and how to get others to believe in you and support risk taking Talks to person to help them identify their preferences in order to find a job that they love Discussion/encouragement to identify and use wellness management and strategies such as WRAP, illness Management Recovery, etc. Joint outcome that could be achieved with peer specialist and vocational provider working together: Persons makes a decision and commitment to seek employment or needed training/education in preparation for employment Choose: Person chooses a direction for working, that is, type of work (or training) person wants to consider based on knowledge of person s interests, values and skills, as well as knowledge of available options Services provided by peer specialists Purpose: Helps person increase awareness of community resources and their potential benefits and how to contribute and earn a place in the community Services provided by vocational providers (NOTE! These services cannot be provided by peer specialists under Medicaid!) Vocational counseling Formal vocational assessment 15

16 Assists person to identify personal strengths that may be accessed for future success Emphasizes importance of ongoing use of wellness strategies Examples: Helps person identify past successes, how they were accomplished and how they might be applied to the job search Reflects with person on the peer specialist s own choice to work within the mental health field while acknowledging that it may not be for everyone Discusses with the person the various vocational resources in the community (such as OVR, Career Link, supported education program or local vocational provider) and in what ways/phases of the job search they have been helpful to other mental health consumers in the county Helps person prepare for appointments with vocational/educational resources through role playing, other skill building/confidence building techniques Works with person to insure that their voice is heard as they connect with vocational services to include such things as: Assists person to build confidence by locating resources about types of jobs, for example, using computer at local library to access O*NET or Occupational Outcome Handbook (OOH) Helps person to develop and assertively ask questions about what person would like to know about different types of work or training May assist person to locate and connect to resources (such as OVR) for formal vocational assessment and help person to identify and prepare questions for these resources (i.e. how to edit their resume, what kind of 16

17 job accommodations are reasonable to ask for, etc.) Assists in mediating/advocating for person s perspective when differences arise between the individual and vocational/treatment providers Helps person with techniques for wellness/stress including exercise/healthy meals Joint outcome that could be achieved with peer specialist and vocational provider working together: Person decides on type of work (or training) to pursue in light of person s interests and values and knowledge of job qualifications Achieve: Person engages in job search or search for training program Services provided by peer specialists Purpose: Stress management during the job search/training process Identifying and using community resources in the vocational area Encouraging/modeling success and tenacity in the job search/training process Examples: Believes in person and cheers them along in the job search process Helps person to identify individuals who can provide a positive job reference as well as how they might address impact of their mental illness on past job performance Helps the person to understand the peer specialist s own fearfulness about job interviews and the peer specialist s own strategies for sustaining hope in the job search process Helps person prepare for job interview including role playing and using wellness strategies to manage stress and anxiety in the Services provided by vocational providers (NOTE! These services cannot be provided by peer specialists under Medicaid!) Job Development to contact employers about potential job openings or customized employment and arranges interviews/follow-up 17

18 process Provides ideas/assistance in preparing cover letters/resume including how other consumers have dealt with holes in their resume Discusses with person their choice to disclose/not disclose their mental health disability and to ask for reasonable accommodations if needed (flex time, mental health day, etc.) and how other persons with mental health disabilities have handled these issues Helps person to think through money issues related to the job (lunch, transportation) until and after paycheck is received including ideas for planning ahead, how to stay within a budget, etc. Shares own experiences about managing time to search for a job and follow-up with potential employers Shares community resources/strategies peer specialist/others have used in preparing for job interview (thrift shop for business attire, job club, etc.) Helps person cultivate and rely on a network of consumer contacts for sharing job search struggles Shares with person what they did and did not say on interviews and assists person to prepare their own interview information Runs a Job Club group for individuals looking for work so that individuals can provide support and set an example for one another Helps person connect with college disability office to get needed supports as a student Assists person with college application, registration, and scheduling process and how to ask for help/accommodations Joint outcome that could be achieved with peer specialist and vocational provider working together: 18

19 Person obtains employment (or is accepted for training program) Keep: Person is hired and begins working Services provided by peer specialists Purpose: Help person to develop and maintain social skills that promote employment viability Promote continued engagement in treatment and other services Services provided by vocational providers (NOTE! These services cannot be provided by peer specialists under Medicaid!) Job coaching to teach person job skills at the work site and to followup with employer Identify need for changes in symptom management techniques in light of work stressors and assists person to reach out for needed help On-the-Job Training Help person to use wellness strategies to manage issues which may interfere with job functioning Examples: Shares own work routine and helps person to plan work/school routine (getting adequate sleep, setting alarm clock, etc.) to be able to get to work/school on time and rested Assists person with trial transportation run (getting bus schedule, finding bus stop, clocking the time to and from, etc.) in over to minimize areas of anxiety related to getting to work Assists the person to develop positive social relationships both on and off the job (i.e. points out to person the kind of things that will annoy others, things to do to get along with others, etc.) Helps person plan for scheduling and keeping treatment and other appointments and using assertive techniques to negotiate needs Assists the individual to recognize the early signs of relapse on the job/in school and how 19

20 to avoid a crisis Talks with person about reporting earnings to SSA and any work incentives they can take advantage of Talks with person about what a job coach can provide and their choice to have supports provided off site versus on the job site. Helps person identify if other symptom management strategies (than those person is currently using) are needed for work such as a work WRAP, a Psychiatric Advance Directive, etc. May run a Work Wellness Recovery Action Plan (WRAP ) group for persons that need a personal plan for working Helps person identify any concerns related to medication and work/school and if changes need to be discussed with psychiatrist Encourages person to build self-worth such as identifying successes at work and how person can build on these Helps the individual develop a network of working individuals for support (job club, clubhouse, etc.) Helps person connect to college support groups such as activeminds.org Identifies potential external stressors such as reactions of family or significant others to person s employment and how to advocate for his/her decisions Understands the persons on the job requests and why they are not being honored and suggests ways of being heard in the future Acknowledges with the person the peer specialist s own struggles to continue to work and to grapple with self-doubt and employer discrimination Talks with person about interpersonal situations at work/in school and personal 20

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